And my big Screw You award of the evening

…goes to the nursing home (and the nursing home doctor) who sent their discharge failure to my ED tonight with copies of their medical record and a hand-written order on the chart “Discharge patient to Emergency Room”.

The patient was accompanied by a social worker who was trying to effect this discharge, as they had been unable to do for several days.  To this individuals’ minor credit, when it was explained that a) there seemed to be no emergency condition, b) that an emergency screening exam would take place, and that c) at the conclusion of that exam, if no emergency condition was found, the patient would be discharged Right Back To Them, and that d) any failure to take the patient back would result in a blizzard of reports to any and every state agency who would listen about their attempted dump, they acquiesced and took their patient back.


Every day I go to work and think I’ve seen it all, and every day I’m surprised, in some way. 

You’d think I’d learn.


  1. I think that the day I cease to become surprised will be the day I need to retire, because (in my case, at least) my ability to be surprised is related to my ability to care for my students.

    But that’s coming from a kindergarden teacher who is working as office support at a reasearch hospital because she needed a break from the needy little monkeys…

  2. Wow, that’s pretty ballsy. A new policy in effect at my dept today: every patient seeking psychiatric care, voluntarily or not, is to have a medical screening exam by ED MD. I have no real idea how to do a screening exam. I am not a primary care doctor. Not only are we the dumping ground for police, FBI, group homes, jail and everything else, but now this. We are NOT the safety net. We identify and treat emergencies. Find your own freaking safety net. Bastards.

  3. Our local veterans hospital decided to convert their ER to an urgent care. They asked us to staff it, so we made an offer. They ended up hired a few IM guys at $20 MORE per hour than our bid. They close at 730pm daily and lately have been calling us to take all ambulance diversion from them after 530pm each day, because the ICU is full.
    Not code 3 sirens… ALL ambulances.
    This is above and beyond the other “I don’t know what epididmytis is, can I send them over there” dumps.

  4. You have got to be kidding me….

  5. HM2(FMF) Heidrich says:

    Gee GruntDoc, you should know better after being a Bn Surgeon.. Marines (and the general population) will never cease trying to find new and peculiar ways to make life interesting, sometimes dumbfounding those of us charged with their care. Its like they’re TRYING to make this stuff up, I swear…

  6. Weell, gee whiz and golly Moses! You’d a thunk that that thar nursin’ home might be ackshully tryin’ ta make a profit, now, woodn’cha?

    Just blogged on that phenomenon – Corporate Healthcare: Mandate to Profit.

    Meanwhile, there’s an actual patient caught up in that hellhole rabbit hole. Nothing like being bundled into a stretcher for a ride to nowhere and back to make one feel loved, wanted and cared for. I presume there was no family in this picture?

    Disgusting, all around.

  7. Anonymous says:

    I like to call this phenomenom “the big dump”. The big dump takes many forms: pre holiday dump, family dump, no appt available dump, I’m sick of this patient dump….etc etc etc.
    The other day I was making the same comment to a co-worker – why am I still amazed by stuff in the ER after all these years? Here’s what she said: you still expect the best of people. I guess that means that I have not given up on humanity yet and neither have you.

  8. That last post was by me

  9. One of the analogous things I see is when doctors don’t realize when a patient needs to be discharged.

    One of my basic guidelines is that when the patient’s current state is not one that would justify an admission to the hospital, then maybe it’s time to go.

  10. Goatwhacker says:

    So why was the nursing home trying to discharge the patient anyway? I’ve run into this a couple of times when a NH patient became violent and was sent to the ER for mental status changes. The NH then refuses to take the patient back.

    This actually has some justification since the NH has legal responsibility to protect their other residents. In my state it’s very tough to find placement for Alzheimer’s patients with aggressive behaviors for just that reason.

    The “discharge to ER” order is pretty low, though. I can’t imagine what that doc was thinking.

  11. Illegitimi non carborundom est, my friend.

  12. To the layman this would seem farfetched but in our ER we deal with it daily. The nursing homes dump patients on us because they don’t want to deal with them. Mental health dumps patients on us because they don’t want to deal with them. The police dump patients on us because they don’t want to deal with the. The other day was the capper, the private locked psych unit in town dumped a patient on us because they “needed a psych eval”!!!!!Um….excuse me but aren’t you a psych facility? I would think perhaps you would know more about psych than we would. The ER…..society’s great dumping ground

  13. I’m convinced nursing homes have two “wheels of fortune” on each unit. The first wheel has each patient’s name on it, the second wheel has the “ED complaint” (chest pain, abd pain, mental status change, etc.). The wheel is spun at least once per shift to unload some patients from the workload.